Clinical Management of Airborne Hazards

What Providers Need to Know

Omowunmi Osinubi, MDAnays Sotolongo, MD

1 in 3report “definite or probable exposure to environmental hazards”

1 in 4report “persistent major health concerns due to deployment exposures”

Airborne Hazards & Post Deployment Health

Burn Pit Smoke Sand and Dust Oil Well Fires

IOM Report 2011

“…service in Iraq or Afghanistan –– might be

associated with long-term health effects, in highly exposed ..or susceptible

populations...”

Airborne Hazards & Open Burn Pit

RegistryPublic Law 112-260

Monitor and ascertain health effects from

exposures

Monitor the health care of Veterans with concerns

Provide high quality health services

1 On-line self-assessment questionnaire (SAQ) 2 Optional in-person

clinical evaluation

Addressing Veterans’ Health Concernsat the Initial In-person Registry Evaluation

• Veteran may discuss:– Upper/lower respiratory symptoms– Physical activity limitations or decreased

ability to exercise – Other health conditions or concerns related to:

• Gastrointestinal, neurocognitive, neuroendocrine, rheumatologic, musculoskeletal, reproductive health and cancer OR

– Have no current health problems, but concerned about possible future health effects of exposures

Airborne Hazards ReferralCase Study #1

48 Year Old OIF Veteran

Non-Smoker

Clinical History• “Breathing problems” & “Hoarseness”

• Started in 2005 in Iraq

• Worsening over time

• Limiting work activities

• Diagnostic work-up to date (normal)• Spirometry, Chest x-ray, cardiac stress

test/echo • Chest CT – “small hiatal hernia”

• Trial of inhalers – “Not helpful”

• Psychiatry - “Severe PTSD”

“I was at Balad,…. I was next to the

burn pit…..I breathed in the

smoke, now I can’t breathe!

“VA Burn-pit Registry”

In-Person Evaluation Process • Providers can review the SAQ using a web portal.

– https://staff.mobilehealth.va.gov/AHBurnPitRegistry/ • Take 5-10 minutes to review the completed Registry SAQ

• Summarize deployment history and exposures• Review symptoms and health history

– Current symptoms- severity and duration– Health conditions- timing and certainty of diagnosis– Tobacco, ETOH, other substance use/abuse– Functional limitations– Concerns about cause of symptoms or health conditions

• Physical examination• Review diagnostic work-up to date• Form an assessment• Create a care plan (including appropriate testing) with patient• Engage in health risk communication

Registry Initial NoteChoose the following on check list: Runny nose/post –nasal drip Chronic sinus congestion Sore throat, hoarseness, change in voice Cough for more than 3 weeks Shortness of breath; breathlessness Gastrointestinal problem

Exposure History • Military Exposures

– Military occupation specialty – Deployment-related

exposures

• Non Military Exposures– Civilian occupational

exposures– Civilian non-occupational

exposures

Military Exposure History

Army Corps of Engineers (10 years) Motor pool construction trucks

o Diesel exhaust fumeso Construction dusts

Military Exposure History

Deployment-related exposures (1/04-6/05) Kuwait: “monster sand and dust storms” Iraq: “Balad burn pit- burned 24/7” Sick often – “Iraqi crud”

Civilian Exposures

Works in waste management Grain dusts Temperature extremes (-40 to 100+ degree F) Heavy physical job demand (> 50 Ibs frequently)

Non-vocational exposures/social history Non-significant

Summary of Exposures

Burn pit smoke

Sand & dust storms

Construction dusts Diesel exhaust

Grain dusts Temperature extremes

Heavy physical work

Psychological trauma

Deployment History and ExposuresViewing instructions is optional and not included in final note

Choose the following exposure concerns: Off base air pollution On base air pollution Hobbies and non military jobs Military jobs while not deployed

Contributory ExposuresBurn Pits

Diesel Exhaust

Construction& Grain Dust

Sand & Dust Storms

Temperature Extremes

AirborneExposures

RADS

Irritant-induced Asthma

Vocal Cord Dysfunction

Dia

gnos

tic W

ork-

Up Work up:

• Cardiac Stress Test• Echocardiography

• Spirometry• Imaging Studies

• Inhaler Ineffectiveness

Diseases:

o Cardiovascular dz

oObstructive Lung dzoInterstitial Lung dz

o ? Vocal Cord Dysfunction

Review Vet’s Diagnostic Work-up to Date

CPRS auto-populates with tests done in past 2 years : Spirometry Chest x-ray Stress Echocardiogram

Diagnostic Evaluation

Spirometry (Pre/Post BD)

Body BoxDLCO

CPET w/ ABGs and 12-

lead ECG

FOT(Pre/Post BD)

FeNO

Diagnostic Test Results• PFT & DLCO

– FEV1 85.4%; FVC 96.9% FEV1/FVC 75%.– FEF 25-75% (55%), +20% bronchodilator– RV 134% predicted– DLCO 114% predicted

• CPET– VO2 max: 88% predicted– VE/MVV: 61% at peak– Appropriate ↓dead space– Throat tightness/discomfort at peak exercise

Diagnostic Test Results

• Forced oscillometry (FOT)↓airways resistance & ↓reactance post bronchodilator

• Expired nitric oxide (FeNO) ↑121 ppb (normal <50 ppb)

(-) airway disease

normal FEV1/FVC

Cardiopulmonary exercise

(+) airway disease

(+) Response in small airways

Resistance FOT

FeNO

ENT Evaluation

• Flexible laryngoscopyBilateral vocal cord nodules Vocal cords normal

movementPharynx is hyperemic Posterior pharyngeal wall

cobble stoningEvidence of acid reflux

What about her poor sleep?

• Polysomnographyobstructive sleep

apnea-hypopnea syndrome & frequent upper airway resistance

Aero Digestive Inflammation

GERD

Chronic Cough

Rhinitis

Sleep Apnea

Summary/Takeaways Case #1

IrIA /RADS:

• Exposure assessment• Symptom onset

• Radiographic Imaging

• Reversible airflow obstruction• PFT, FOT, CPET

VCD:

• Stridor vs. wheezing• Awareness of VCD

• Identify potential cause(s)/trigger(s)

• Flexible laryngoscopy

• Functional impairment

Airborne Hazards ReferralCase Study #2

31 year old OIF Marine Corps Veteran

Chief Concerns

• Severe shortness of breath since Iraq

• Decreased exercise capacity

• Multiple episodes of acute respiratory distress

Military Exposure History

Combat truck convoysSand and dust storms

Military Exposure History Contd.

Post Deployment History

Progressive SOB & DOE, OrthopneaCurrent smoker 15 pack-year Frequent hospitalizations for respiratory exacerbations

Comorbid conditionsIDDMHTNGERDPTSDSleep apnea

Unable to work due to respiratory impairment

Airborne Hazard Concerns - Clinical Assessment • Physical exam & oxygen sat

• Chest X-ray (PA and lateral)

• Pulmonary function tests

• Allergy consult

• Cardiac evaluation - EKG, Echo,

• Pulmonary consult

Diagnostic Work-up

Chest x-ray:

R costophrenic angle blunting

Mild hyperaeration

Diagnostic Work-up (Contd.)Allergy ConsultImmune deficiency excluded

PFT:Diffusion:

DLCO= 29.5 (101%)

Spirometry: FV loops-curvilinear FEV1/FVC= 0.70 FEV1= 3.85L (77%) No BD response MVV ↓60 l/min

Lung Volumes: TLC= 7.90L (96%) VA= 5.13 L (67%) RV/TLC= 35%

Diagnostic Work-up (Contd.)EKG: Sinus tachycardia Left atria enlargement No change from study 8

months prior

Echocardiogram: Trace mitral regurgitation Mild tricuspid regurgitation LV systolic function normal

– estimated EF = 55% Pulmonary artery systolic

pressure not assessed Technically suboptimal

study

What types of additional work-up would be appropriate for this Veteran?

“It was when I was under the care of a pulmonologist ...

that my condition … received a more thorough workup”

High Resolution Chest CT Imaging ILD Evaluation by HRCT:• Axial Scans:

– Supine & Prone• Full inspiration• 1-1.5 mm collimation

at 1 to 2 cm intervals• Dynamic, during forces

expiration views:– Aortic Arch– Carina– Above diaphragm

Patient’s HRCT Findings:• CT 4/2013 & 7/2013:

– Mild emphysema– Mosaic perfusion– Mild bronchitis– RUL minor ground

glass– No ILD/effusion/LAD

• Findings unchanged(CT 4/2013 vs. 7/2013)

Six-minute Walk Test

BMI: 26.8 (overweight)WHR: 0.96

Baseline SpO2: 94%

6MWD: 350m (51% pred)Peak HR: 134/min

HR @2min post: 108/minPost exertion SpO2: -11% (84%)

Other: Requires 2 LPM oxygen to stay above 90%

What about lung biopsy?

• When is lung biopsy indicated?• What type of biopsy is indicated?

– Bronchoscopy with biopsy– Surgical lung biopsy (VATs)

• What are the limitations of each type?• What are the possible complications?

Hospitalized in 2013

Presented with acute respiratory distressBronchoscopy:

• Early granulomatous reaction • Consistent with silicosis• Larger tissues sample was recommended

Constrictive Bronchiolitis in OEF/OIF

NEJM: CB in soldiers exertional dyspnea38 of 49 (78%) diagnosed with CB

• PFTs, CPET within normal limits• Moderate reduction in DLCO

ATS Research abstract: National Jewish Hospital

US Army Public Health Command (USAPHC): Epidemiologic evidence to date is inadequate to

support or refute an association between deployment and chronic respiratory conditions

Pulmonary Findings in Iraq/Afghanistan Deployers

Centrilobular Nodularity

Mosaic air trapping

Emphysema

Right Upper & Lower Lobe Open Biopsies

Preliminary Pathology report:Mild anthracosilicotic depositsHemosiderin-laden intra-alveolar

macrophagesDx: Smoking-related interstitial lung disease

Addendum to pathology report (SEM/EDXA)Particles contain Si, Al, & O; K & Na

(environmental silicates)Rare particles Ti, Fe & Cr (possibly steel)

What is the Diagnosis?RB-ILD

CB

DIP

What is the Management?RB-ILD

CBsteroids, macrolides

DIP+ steroids

Summary/Takeaways Case #2

High Resolution CT• Assess lung parenchyma

for fibrosis

Constrictive Bronchiolitis• Rare disease• Irreversible (steroids may

help)• ? Clinical course in

diagnosed soldiers

Lung Biopsy• Gold standard for

interstitial lung disease• ? Benefit/Risk ratio

B-ILD and DIP• Related to smoking• Rx: STOP SMOKING

Airborne Hazard Concerns Iraq & Afghanistan War Veterans

• Many combat Veterans have airborne hazard exposure concerns.

– Have high index of suspicion for upper & lower respiratory problems & a low bar for further evaluation.

– Identify physical /behavioral health co-morbidities early and treat.

• Case management services to support change in lifestyle interventions.

THANK YOU !

Questions?

New Jersey War-related Illness and Injury Study Center

http://www.warrelatedillness.va.gov/

omowunmi.osinubi@va.gov 1-800-248-8005anays.sotolongo@va.gov